Choosing right the therapy for herniated disks

Should patients with herniated disks undergo surgery or tough it out with physical therapy, exercise, and painkillers? According to results from the Spine Patient Outcomes Research Trial (SPORT), patients who undergo surgery have better outcomes than those who receive nonoperative treatment. However, the difference is quite small. In the one to two years after their initial symptoms appear, most patients in each group show considerable improvement in both their ability to function and in their overall quality of life.

The SPORT findings — which were published in JAMA (2006;296:2441-2450 and 2451-2459)—are the first from a series of groundbreaking studies designed to compare back surgery with nonoperative treatment. A $15-million project funded by NIH, the trial marks the first time the effectiveness of back surgery has been measured using both randomized and observational cohorts. Recently, The Clinical Advisor senior editor Nelly Edmondson Gupta spoke with SPORT investigator Jon D. Lurie, MD, associate professor of medicine at Dartmouth Medical School in Hanover, N.H., about what these findings mean for primary-care providers (PCPs) and their patients with herniated disks.

Q: What are the main findings of SPORT thus far?A: In the randomized trial, both surgical and nonoperatively treated patients improved substantially over the first one to two years, although at every follow-up point, the surgery group did a little bit better. However, there was substantial nonadherence to randomized treatment. Many people assigned to surgery got better without it, while many patients in the nonoperative group were unable to tolerate the pain and opted for surgery. In the observational study, where there was much less crossover, we found a statistical advantage to surgery at all time points. It's important to note that in the observational study, patients who chose surgery were much more symptomatic.

The bottom line is, if you look at all the data together, there appears to be an advantage to surgery. On the other hand, many people choose surgery because they fear they'll end up permanently disabled if they don't, but that did not happen in our study.

Q: How should PCPs advise patients with back pain?A: What the SPORT and other recent studies suggest is that if a patient has had symptoms for six weeks despite treatment, it's time to consider surgery. To a large extent, the choice of surgery or nonoperative care will depend on how much pain the patient can tolerate, how much the pain is interfering with his life, and whether he can take time off to manage symptoms on his own. If patients can afford it financially, psychologically, and socially, they'll do well without surgery. On the other hand, if the pain is intolerable or is preventing patients from doing things they can't afford not to do, they should consider surgery.

When it comes to specific nonoperative management strategies, I suggest PCPs follow the guidelines published by the U.S. Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) in 1994. Still relevant today, the guidelines are available online.

Q: Which patients are especially good candidates for nonoperative treatment?A: The best candidates for nonoperative treatment are patients whose pain levels are tolerable after manipulation, physical therapy, heat or cold treatment, and activity alteration—in short, patients who can manage their symptoms for long enough to get better and who prefer to avoid surgery. Only a few patients are not good candidates for nonoperative treatment, including those with cauda equina compression syndrome. This condition occurs when herniated disks press on the lower spinal cord, causing patients to suffer bowel and bladder incontinence and other serious problems; the syndrome can also result in paralysis. But this condition is rare, and it can be ruled out with a careful history and physical exam.

Q: Are there other situations in which delaying or avoiding surgery could lead to highly negative outcomes?A: Progressive weakness is a definite indication for surgery. If a patient who has a little bit of weakness in a toe comes back with foot drop that is progressing, it's time for surgical intervention to prevent permanent nerve damage. On the other hand, nonprogressive pedal weakness is not necessarily an indication for surgery.

Q: Some observers say that since surgery did not show a convincing benefit over nonoperative care, a sham surgical trial should be done. Do you agree?A: Technically, this is correct; in order to have indisputable evidence of a clear benefit from surgery over and above the placebo effect, you would need to do a sham surgical trial. However, I do not think such experiments should be done in patients with disk herniation. The accumulated evidence gives us reasonable confidence that we know what the outcomes of surgical and nonoperative care will be: There is some benefit to surgery, but it's not the right choice for everyone. In other instances—fusion for low back pain—where the benefit is more of a question, a sham study might be more reasonable.

Q: Are PCPs currently doing anything wrong in their treatment of back pain?A: There is no evidence they are. However, if you look at other research, you will find that patients of chiropractors are more satisfied with their care than patients of other providers. That is because relative to PCPs, chiropractors spend a large amount of time with patients, and during that time, they provide more information than clinicians do. In addition, chiropractors tend to offer patients more validation about their back pain, treating it as a real concern and supporting them through it.

Q: Should patients who jog regularly continue to run despite their back pain?A: People do better if they stay as active as they can tolerate; in fact, the more active they are, the better they tend to do. As a general rule of thumb, patients should stop activities that exacerbate their leg pain but continue with activities that exacerbate their back pain. One of the worst things people with herniated disks can do is sit for long periods of time because pressure on disks is greater when patients are sitting or bending than when they are upright or lying down. Lying down and standing up tend to be more comfortable; bending and sitting tend to be uncomfortable.

Q: How can the SPORT results help PCPs guide their patients with sciatica to the most appropriate treatment?A: PCPs should inform their patients of these results so patients can make informed choices about their treatment. Those who can manage their symptoms can be confident that over a year or two, they're going to do just fine. On the other hand, some patients with severe pain will say, “You're crazy; I can't live like this for two years.” These are the people who ought to see a surgeon.

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